African American families face the challenge of having limited resources. The direct costs of schizophrenia often exceed the median family income of African Americans. Moreover, African Americans are more likely to believe that mentally ill individuals are violent.
Yet African American families are more likely to retain schizophrenic members in their midst despite limited resources. Part of the reason is that African Americans are more tolerant of the often unconventional and unpredictable behavior of a family member with schizophrenia. African Americans are less likely than European Americans to believe that individuals with schizophrenia should be blamed and punished for violent behavior. European American families are more likely to feel burdened and rejecting toward the family member with schizophrenia. Cultural factors may therefore be more important then socioeconomic status in determining whether family members will be caretakers.
Although the idea that family dynamics “cause” schizophrenia has been discredited, family relationships can certainly affect the course of the illness. However, factors that contribute to poor outcome differ in European American and African American families.
High emotionality and family intrusiveness have been shown consistently to predict poor outcome in European Americans with schizophrenia. This does not appear to be the case in African Americans. Critical comments by relatives that were perceived as expressed criticism by European American and Latino family members with schizophrenia were not perceived consistently as criticism by African Americans with schizophrenia. Moreover, in European Americans, family intrusiveness and critical comments, elements considered important in families with high emotionality, showed no association with outcome. Presumably, such behavior was interpreted as displaying more concern in African American families.
The take-home message is that family factors do play an important role in outcomes of African Americans with schizophrenia. African Americans tend to be supportive and to continue family involvement, but they tend to be fearful of the mentally ill. Moreover, the relationships seen in family dynamics and schizophrenia in European Americans may be very different in African Americans. Behavior that is considered toxic in other cultures may be protective in African American cultures. In conclusion, culture is important in family interactions. However, findings about the relationship between schizophrenia and family members in European American families simply may not apply to African Americans and other ethnic minorities.
African Americans have more illness burden, because they do not have the same access to services and often receive suboptimal treatment. African Americans are more likely to be homeless or in prison, settings in which treatment is suboptimal. Hospitalization is more common, especially involuntary admissions, and the disposition after discharge is often medication-only or emergency room care. Preferential treatment such as day treatment or case management are less likely to be available.
Schizophrenia in African Americans
Racial differences in income may contribute to the lack of treatment access. Although African Americans have 60% of the income of European Americans, they have only 10% as much family wealth because of slavery and later job discrimination. Only recently has wealth accumulation become widely available. As noted earlier, direct costs for the treatment of schizophrenia exceed the median family income of African Americans.
Yet African Americans with schizophrenia are more likely to be cared for within the family. Without disposable income, patients sometimes have to choose between necessities and medications. Family members can access only the most rudimentary care.
Although income is important, other factors play a part. As noted earlier, issues such as misdiagnosis persisted even when income was controlled. The Surgeon General’s Report noted that when income was taken into account, ethnic disparities still persisted.
Moreover the National Comorbidity Study Replication also reported less access to care for ethnic minorities, even when income was controlled. When we look closely at pharmacotherapy we find similar provider and patient issues that contribute to misdiagnosis.
William B. Lawson
Clinical handbook of schizophrenia / edited by Kim T. Mueser, Dilip V. Jeste.
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